Bleeding Rates Decrease When Hospitals Up Use of Radial PCI

Download this article's Factoid (PDF & PPT for Gold Subscribers)


Hospitals that increased their use of transradial percutaneous coronary intervention (PCI) in recent years are achieving lower rates of access-site and overall bleeding than centers maintaining a primarily femoral approach, according to a registry study of US hospitals presented June 4, 2014, at the American Heart Association’s Quality of Care and Outcomes Research 2014 Scientific Sessions in Baltimore, MD.    

The study was simultaneously published online, ahead of print in Circulation: Cardiovascular Quality and Outcomes.   

Methods
Using the National Cardiovascular Data Registry CathPCI Registry, Steven M. Bradley, MD, MPH, of Veterans Affairs Eastern Colorado Health Care System (Denver, CO), and colleagues examined facility-level changes in use of transradial PCI at 818 hospitals in the United States between July 2009 and June 2012. All included facilities used radial PCI in no more than 10% of all cases at baseline.
Each hospital’s change in transradial from baseline through 3 years was divided into 4 categories of increase:
  • Very low (n = 327; from 0.2% to 1.8%)
  • Low (n = 314; from 0.9% to 8.9%)
  • Moderate (n = 136; from 1.6% to 27.2%)
  • High (n = 41; from 1.0% to 45.1%) 
 

 

Institutions with higher rates of transradial increase were more likely to be teaching hospitals and less likely to be located in Western states.

By 2012, approximately 40% of hospitals continued to use transradial PCI in less than 2% of patients. However, another 40% of hospitals increased to approximately 9%. Only 5% of hospitals in the study achieved rates of transradial PCI approaching 50%.   

Less Bleeding Linked with More Radial Use   

For the primary outcome of access-site bleeding, declines between the first and last quarter of observation were seen across all categories of transradial access use. However, compared with hospitals with very low or low increases, those with moderate or high increases reported greater declines in risk-adjusted access site bleeding (RR 0.45 vs 0.65; P = .002 for comparison).    

Results were similar for access-site bleeding and overall bleeding rates in secondary analyses that adjusted for antithrombotic strategy and use of vascular closure devices in addition to bleeding risk (table 1).   

Table 1. Bleeding Risk by Hospital Change in Radial Use: RR (95% CI)a

 

Very Low

Low

Moderate

High

P for Interaction

Access Site Bleeding

0.62
(0.52-0.75) 

0.79
(0.68-0.90) 

0.45
(0.37-0.55) 

0.47
(0.32-0.69) 

< .001

Overall Bleeding Outcomes

0.70

(0.62-0.80) 

0.79

(0-0.87) 

0.58
(0.49-0.68) 

0.48
(0.36-0.63) 

< .001

aRR for last vs first quarter of observation; adjusted for antithrombotic strategy and use of vascular closure devices.

While temporal trends in contrast use were similar across hospital categories of change in transradial use, fluoroscopy time was modestly higher at hospitals with moderate or high increases compared with those with little change (1.3 minutes vs 0.2 minutes; P = .01).    

Bleeding Declines Sustained    

“Our findings suggest that facilities transitioning to greater use of [transradial procedures] are achieving larger reductions in periprocedural bleeding than facilities that continue to use a predominantly femoral approach for PCI,” Dr. Bradley and colleagues write.    

While they acknowledge that “bleeding complication rates have continued to decline in recent years and may reflect the continued changes in antithrombotic strategies, with greater use of bivalirudin and less use of glycoprotein IIb/IIIa inhibitors,” significant declines in bleeding rates remained after adjustment for antithrombotic strategies and use of vascular closure devices.    

As to the modest rise in fluoroscopy times, Dr. Bradley and colleagues say it “likely reflects increased use of fluoroscopy to guide operators through upper extremity vessels or during coronary artery cannulation.” Furthermore, it is “unclear whether this increase in fluoroscopy time reflects significant differences in radiation dose and subsequent risk of adverse patient outcomes,” they note.    

Radial Myths Debunked by Data    

“I think this is another reflection of the trend that many of us have sensed in increasing use of radial across the [United States],” Ian C. Gilchrist, MD, of Hershey Medical Center (Hershey, PA), told TCTMD in a telephone interview.    

“There has been this underlying concern that the learning curve or the relatively low volume of some US operators was going to be a hazard as we switched over to a radial approach, and you can see in each of the groups there is nothing but benefit,” he said. “If you do a little more radial, you get a little benefit. If you do a lot more, you get even greater benefit.”    

Dr. Gilchrist added that the data also contradict the argument that studies comparing radial and femoral procedures have not used modern femoral procedures with improved antithrombotics and closure devices as the comparator. “Even subtracting out this secular change over time, you still do better with radial, as this study shows,” he commented.   

Finally, Dr. Gilchrist observed that the increase in fluoroscopy time for radial procedures seen in the study is somewhat deceiving since the NCDR database does not measure radiation dose but rather the time that the X-ray tube is turned on.

“A minute of fluoroscopy time is measured as a minute whether it is actual fluoroscopy or cineangiography, which uses a multitude of times greater radiation than fluoroscopy,” he said. In the United Kingdom, where radial accounts for 50% of all PCIs, fluoroscopy and contrast use have been shown to be similar in radial vs femoral procedures, he reported, adding that experience and comfort with the technique is the likely explanation.    

 


Source:

Bradley SM, Rao SV, Curtis JP, et al. Change in hospital-level use of transradial percutaneous coronary intervention and periprocedural outcomes: insights from the National Cardiovascular Data Registry. Circ Cardiovasc Qual Outcomes. 2014;Epub ahead of print.


Disclosures:

  • Drs. Bradley and Gilchrist report no relevant conflicts of interest. 


Related Stories:

Comments